First-line diagnosis of paediatric pneumonia in emergency: lung ultrasound (LUS) in addition to chest-X-ray (CXR) and its role in follow-up

Systematic review and meta-analysis of the accuracy of lung ultrasound and chest radiography in diagnosing community acquired pneumonia in children

Chest radiography (CXR) is commonly used for diagnosing childhood pneumonia, but concerns about radiation exposure have raised interest in using radiation-free lung ultrasound (LUS) as an alternative imaging modality. Therefore, we designed this meta-analysis to compare the accuracy of LUS and CXR for diagnosing childhood pneumonia. We searched 8 databases and 1 clinical trial registry for studies published from inception to March 2023. Studies assessing lung ultrasound and chest radiography for diagnosing childhood pneumonia were included. Two reviewers independently screened literature, extracted data, and assessed the risk of bias using the QUADAS-2 tool for each study. Meta-analysis was conducted using a random-effects model, and pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic (SROC) curve were assessed. Statistical analyses were performed using Meta-Disc 1.4, RevMan 5.4, and Stata 17.0 software. Heterogeneity was examined, and subgroup analysis was conducted to explore the accuracy of lung ultrasound in diagnosing childhood pneumonia. Out of the 4089 screened articles, 30 studies were included, encompassing a total of 4546 children. Of those, 3257 were diagnosed with pneumonia, 3190 through LUS, and 2925 via CXR. The meta-analysis showed that the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of LUS were 0.940 (95% CI 0.930-0.949), 0.855 (95% CI 0.835-0.873), 7.561 (95% CI 4.956-11.536), 0.08 (95% CI 0.056-0.113), and 110.77 (95% CI 62.156-197.40), respectively. The combined area under the SROC curve was 0.9712, Q index = 0.9218. For CXR, the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.893 (95% CI 0.881-0.905), 0.906 (95% CI 0.889-0.921), 18.742 (95% CI 7.551-46.520), 0.105 (95% CI 0.062-0.180), and 237.43 (95% CI 74.080-760.99), respectively. The combined area under the SROC curve was 0.9810, Q index = 0.9391. Subgroup analysis showed that the implementation location, interval between lung ultrasound and chest radiography, and operator experience had no impact on the accuracy of lung ultrasound in diagnosing childhood pneumonia. Existing evidence suggests that lung ultrasound has high accuracy for diagnosing childhood community-acquired pneumonia. Compared with chest radiography, lung ultrasound has higher sensitivity, similar specificity, and advantages such as radiation-free, lower cost, simplicity of operation, and ease of follow-up, making it an important imaging modality for diagnosing childhood pneumonia.

Point-of-Care Ultrasound for Earlier Detection of Pediatric Pneumonia

Case Presentation

An 8-month-old infant presented to a general emergency department with chief complaints of rhinorrhea, decreased activity, and fever. A point-of-care lung ultrasound (LUS) was performed at bedside with potential early findings of pneumonia. Based on these findings on LUS, a chest radiograph (CXR) was ordered and performed with no acute findings. He was discharged without antibiotics based on these findings; unfortunately, he returned two days later with worsening symptoms requiring chest tube placement, mechanical ventilation, and prolonged hospitalization for complicated bacterial pneumonia.

Discussion

Pneumonia is a major cause of pediatric morbidity and mortality worldwide. Despite evidence supporting the utilization of LUS for the diagnosis of pediatric pneumonia, CXR remains the default imaging for clinical decision-making in most settings. In this case, earlier antibiotics and higher reliance on LUS for clinical decision-making may have prevented the morbidity associated with this hospitalization.

Comparison of lung ultrasound and chest radiography for detecting pneumonia in children: a systematic review and meta-analysis

BACKGROUND

Lung ultrasound (LUS) is recommended as a reliable diagnostic alternative to chest X-ray (CXR) for detecting pneumonia in children.

METHODS

PubMed, Embase, and Cochrane Library databases were used to identify eligible studies from their inception until April 2023. The investigated diagnostic parameters included sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curves (AUC).

RESULTS

Twenty-six studies involving 3,401 children were selected for meta-analysis. The sensitivity, specificity, PLR, NLR, DOR, and AUC of LUS for detecting pneumonia in children were 0.95, 0.92, 12.31, 0.05, 108.53, and 0.98, respectively, while the sensitivity, specificity, PLR, NLR, DOR, and AUC of CXR were 0.92, 0.93, 24.63, 0.08, 488.54, and 0.99, respectively. The sensitivity of LUS was higher than that of CXR for detecting pneumonia in children (ratio: 1.03; 95% CI: 1.01-1.06; P = 0.018), whereas the DOR of LUS was significantly lower than that of CXR (ratio: 0.22; 95% CI: 0.06-0.85; P = 0.028).

CONCLUSIONS

This study found that the diagnostic performance of LUS was comparable to that of CXR for detecting pneumonia, and the sensitivity of LUS was superior to that of CXR.

Accuracy of Thoracic Ultrasonography for the Diagnosis of Pediatric Pneumonia: A Systematic Review and Meta-Analysis

As an emerging imaging technique, thoracic ultrasonography (TUS) is increasingly utilized in the diagnosis of lung diseases in children and newborns, especially in emergency and critical settings. This systematic review aimed to estimate the diagnostic accuracy of TUS in childhood pneumonia. We searched Embase, PubMed, and Web of Science for studies until July 2023 using both TUS and chest radiography (CR) for the diagnosis of pediatric pneumonia. Two researchers independently screened the literature based on the inclusion and exclusion criteria, collected the results, and assessed the risk of bias using the Diagnostic Accuracy Study Quality Assessment (QUADAS) tool. A total of 26 articles met our inclusion criteria and were included in the final analysis, including 22 prospective studies and four retrospective studies. The StataMP 14.0 software was used for the analysis of the study. The overall pooled sensitivity was 0.95 [95% confidence intervals (CI), 0.92-0.97] and the specificity was 0.94 [95% CI, 0.88-0.97], depicting a good diagnostic accuracy. Our results indicated that TUS was an effective imaging modality for detecting pediatric pneumonia. It is a potential alternative to CXR and a follow-up for pediatric pneumonia due to its simplicity, versatility, low cost, and lack of radiation hazards.

The role of Lung Ultrasound in the diagnosis of SARS-COV-2 disease in pregnant women

AIM

To evaluate the role of lung ultrasound (LUS) in recognizing lung abnormalities in pregnant women affected by COVID-19 pneumonia.

MATERIALS AND METHODS

An observational study analyzing LUS patterns in 60 consecutively enrolled pregnant women affected by COVID-19 infection was performed. LUS was performed by using a standardized protocol by Soldati et al. The scoring system of LUS findings ranged from 0 to 3 in increasing alteration severity. The highest score obtained from each landmark was reported and the sum of the 12 zones examined was calculated.

RESULTS

Patients were divided into two groups: 26 (43.3%) patients with respiratory symptoms and 32 (53.3%) patients without respiratory symptoms; 2 patients were asymptomatic (3.3%). Among the patients with respiratory symptoms 3 (12.5%) had dyspnea that required a mild Oxygen therapy. A significant correlation was found between respiratory symptoms and LUS score (p < 0.001) and between gestational weeks and respiratory symptoms (p = 0.023). Regression analysis showed that age and respiratory symptoms were risk factors for highest LUS score (p < 0.005).

DISCUSSION

LUS can affect the clinical decision course and can help in stratifying patients according to its findings. The lack of ionizing radiation and its repeatability makes it a reliable diagnostic tool in the management of pregnant women.

Use of Lung Sonography in the Assessment and Confirmation of Pulmonary Complications in the Pediatric Patient

Objective:

To determine if lung sonography is accurate in assessing and confirming pulmonary compromise and thereby reduce the risk of x-ray exposure, for pediatric patients.

Materials and Methods:

This study was a systematic review of individual published studies. PubMed was the only database used for the article search. A review by a committee of contributors determined whether studies met the specific inclusion criteria. Studies reviewed had participants between the ages 0 and 18 years, with lung compromise of varying pathophysiological diagnoses. Each intervention was coded by levels of evidence; grading of recommendations, assessment, development, and evaluation (GRADE); the evidence alert traffic light grading system; and risk of bias in nonrandomized studies of interventions. Each article was evaluated using the Cochrane assessment of bias and GRADE evidence tables.

Results:

Thirty-seven articles were retrieved. Of those, 21 articles were removed following title and abstract screening. With 16 articles remaining, only one duplicate was removed. Based on the 15 articles extracted, in full-text versions, only two articles were noted to be irrelevant, and one article was not provided in English. Only 12 articles met the eligibility criteria, but two articles had to be removed because they were systematic reviews and not individual studies. The final analysis was based on 10 articles that met the inclusion criteria.

Conclusion:

Once reviewed, all 10 articles indicated that lung sonography had high accuracy and confirmation of lung compromise, which spanned multiple pulmonary diagnoses, in pediatric patients. When used by a trained clinician, lung sonography was as highly effective in comparison to other diagnostic tools, such as a chest radiograph and computed tomography.

The utility of chest x-ray and lung ultrasound in the management of infants and children presenting with severe pneumonia in low-and middle-income countries: A pragmatic scoping review

Background

Chest x-ray (CXR) is commonly used (when available) to support clinical management decisions for child pneumonia and provide a reference standard for diagnosis in research studies. However, its diagnostic and technical limitations for both purposes are well recognised. Recent evidence suggests that lung ultrasound (LUS) may have diagnostic utility in pneumonia. This systematic scoping review of research on the utility of CXR and LUS in the management of severe childhood pneumonia aims to inform pragmatic guidelines for low- and middle-income countries (LMICs) and identify gaps in knowledge.

Methods

We included peer-reviewed studies published between 2000 and 2020 in infants and children aged from one month to nine years, presenting with severe pneumonia. CXR studies were limited to those from LMICs, while LUS studies included any geographic region. LUS and CXR articles were mapped into the following themes: indications, role in diagnosis, role in management, impact on outcomes, and practical considerations for LMIC settings.

Results

85 articles met all eligibility criteria, including 27 CXR studies and 58 LUS studies. CXR studies were primarily observational and examined associations between radiographic abnormalities and pneumonia aetiology or outcomes. The most consistent finding was an association between CXR consolidation and risk of mortality. Difficulty obtaining quality CXR images and inter-reader variability in interpretation were commonly reported challenges. Research evaluating indications for CXR, role in management, and impact on patient outcomes was very limited. LUS studies primarily focused on diagnostic accuracy. LUS had higher sensitivity for identification of consolidation than CXR. There are gaps in knowledge regarding diagnostic criteria, as well as the practical utility of LUS in the diagnosis and management of pneumonia. Most LUS studies were conducted in HIC settings with experienced operators; however, small feasibility studies indicate that good inter-operator reliability may be achieved by training of novice clinicians in LMIC settings.

Conclusions

The available evidence does not support the routine use of CXR or LUS as essential tools in the diagnosis and initial management of severe pneumonia. Further evaluation is required to determine the clinical utility and feasibility of both imaging modalities in low-resource settings.

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia

OBJECTIVES

To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.

STUDY DESIGN

We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.

RESULTS

A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period.

CONCLUSIONS

Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases.

Lung Ultrasonography Beyond the Diagnosis of Pediatrics Pneumonia

Pneumonia is a prevalent disease with considerable morbidity and mortality among the pediatric population. Early diagnosis and swift commencement of the correct treatment are vital for a favorable clinical outcome. Along with history-taking and clinical examination, imaging modalities commonly used, lung ultrasound provides a bedside, less invasive, radiation-free alternative to diagnose pneumonia when compared with other images such as chest x-ray (CXR) and computed tomography (CT) scan. It is therefore of the utmost magnitude to inspect the evidence of its accuracy and reliability in the diagnosis of this condition. The goal of this study is to look into the available data supporting the use of lung ultrasound in the diagnosis of juvenile pneumonia, its relevance in distinguishing between viral and bacterial diseases, and its superiority as compared to other diagnostic methods. As mentioned, early detection and differentiation of the type of pneumonia can reduce unnecessary antibiotic prescriptions and provide patients with a better prognosis, as well as the ability to predict the course of the disease and the need for advanced care or the development of complications. An extensive literature search of two popular online medical websites (PubMed and Embase) was conducted in this review, concentrating on studies that examined the role of lung ultrasound in the diagnosis of pediatric pneumonia published in the last five years. Only studies published in the English language were included in this review. With high sensitivity and specificity, lung ultrasound appeared to be a promising tool not only for pediatric pneumonia diagnosis, but also for treatment guidance and disease follow-up, especially when combined with clinical presentation and laboratory findings.

Ten Years of Pediatric Lung Ultrasound: A Narrative Review

Lung diseases are the most common conditions in newborns, infants, and children and are also the primary cause of death in children younger than 5 years old. Traditionally, the lung was not thought to be a target for an ultrasound due to its inability to penetrate the gas-filled anatomical structures. With the deepening of knowledge on ultrasound in recent years, it is now known that the affected lung produces ultrasound artifacts resulting from the abnormal tissue/gas/tissue interface when ultrasound sound waves penetrate lung tissue. Over the years, the application of lung ultrasound (LUS) has changed and its main indications in the pediatric population have expanded. This review analyzed the studies on lung ultrasound in pediatrics, published from 2010 to 2020, with the aim of highlighting the usefulness of LUS in pediatrics. It also described the normal and abnormal appearances of the pediatric lung on ultrasound as well as the benefits, limitations, and possible future challenges of this modality.

Relationship between Radiological Findings with Bacterial Etiology of Community Acquired Pneumonia in Pediatric Population

Pneumonia continues to be a major cause of morbidity and mortality in children. Pneumonia is the leading killer of children worldwide. For the diagnosis of pneumonia, the World Health Organization has introduced guidelines for the management of cases to reduce the mortality of these diseases on the basis of simple clinical signs followed by the empirical treatment with antibiotics. More than 99% of deaths related to pneumonia among children occur in countries having a low and middle income. To study the Radiological finding of Community-Acquired Pneumonia (CAP) in children. Across sectional study was conducted in which the sample size for the study was calculated from the expected prevalence of CAP based on other studies (74%). The sample size calculated by the required criterion for this study is 96. I was able to cover 118 patients as per the inclusion criteria in this study. The Patients of pediatric age groups and either sex attending tertiary care hospital with complaints suggestive of CAP. In this study total number of patients are 118 included who presented with the signs and symptoms suggestive of pneumonia. The findings of chest X-Ray of Right Lung with respect to different bacterial agents. Consolidation of the Right upper lobe is found to be statistically significant with respect to Streptococcus pneumonia and consolidation of the right lower lobe is found to be statistically significant with respect to bacteria Staphylococcus aureus whereas there is no statistically significant association with respect to other bacteria. The radiological finding of CAP in children attending pediatric OPD was observed that there was no association with any other bacteria.

Chest Computed Tomography (CT) as a Predictor of Clinical Course in Coronavirus Disease

BACKGROUND Chest imaging may be taken into consideration in detecting viral lung infections, especially if there are no tests available or there is a need for a prompt diagnosis. Imaging modalities enable evaluation of the character and extent of pulmonary lesions and monitoring of the disease course. The aim of this study was to verify the prognostic value of chest CT in COVID-19 patients. MATERIAL AND METHODS We conducted a retrospective review of clinical data and CT scans of 156 patients with SARS-CoV-2 infection confirmed by real-time reverse-transcription polymerase-chain-reaction (rRT-PCR) assay hospitalized in the Central Clinical Hospital of the Ministry of the Interior in Warsaw and in the Medical Centre in Łańcut, Poland. The total severity score (TSS) was used to quantify the extent of lung opacification in CT scans. RESULTS The dominant pattern in discharged patients was ground-glass opacities, whereas in the non-survivors, the dominant pulmonary changes were consolidations. The non-survivors were more likely to have pleural effusion, pleural thickening, lymphadenopathy, air bronchogram, and bronchiolectasis. There were no statistically significant differences among the 3 analyzed groups (non-survivors, discharged patients, and patients who underwent prolonged hospitalization) in the presence of fibrotic lesions, segmental or subsegmental pulmonary vessel enlargement, subpleural lines, air bubble sign, and halo sign. CONCLUSIONS Lung CT is a diagnostic tool with prognostic utility in COVID-19 patients. The correlation of the available clinical data with semi-quantitative radiological features enables evaluation of disease severity. The occurrence of specific radiomics shows a positive correlation with prognosis.

Lung Ultrasound for the Diagnosis of Neonatal Respiratory Distress Syndrome: A Meta-analysis

Supplemental digital content is available in the text.

Chest radiography is the primary imaging modality used for the assessment of neonatal respiratory distress syndrome (NRDS) in newborns. However, excessively exposing a growing neonate to harmful ionizing radiation may have long-term consequences. Some studies have shown that lung ultrasound (LUS) is helpful in the diagnosis of NRDS. A comprehensive search was carried out using PubMed, Embase, and the Cochrane Library to identify studies in which newborns with clinically suspected NRDS were assessed by LUS. Two investigators independently screened the literature and extracted the data. Any discrepancies were resolved via discussion with the senior author. Study quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 tool, and pooled sensitivity and specificity of various LUS findings for diagnosing NRDS were determined. Summary receiver operating characteristic curve was used to assess the overall performance of LUS. Ten studies with a total of 887 neonates were included in this meta-analysis. There was significant heterogeneity across the included studies. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for the diagnosis of NRDS using LUS were 0.92 (95% confidence interval [CI], 0.89–0.94), 0.95 (95% CI, 0.93–0.97), 20.23 (95% CI, 8.54–47.92), 0.07 (95% CI, 0.03–0.14), and 455.30 (95% CI, 153.01–1354.79), respectively. Furthermore, the summary receiver operating characteristic area under the curve was calculated to be 0.9888. The main LUS characteristics of NRDS include bilateral white lung, pleural line abnormalities, and lung consolidation. In summary, LUS is a highly valuable diagnostic technology that complements chest radiography in the diagnosis and follow-up monitoring of NRDS.

Review of lung ultrasound findings in coronavirus disease 2019 (COVID-19): Effectiveness, applications and approach to lung ultrasound during times of a pandemic

As of 22 April 2020, there are 6 countries with >100,000 cases, 21 countries with 1000 to 10,000 confirmed cases and 53 countries with between 1000 and 10,000 confirmed cases of COVID-19. Six articles (5 research articles and 1 review article) with a total of 159 cases delineating the equipment, protocol, techniques, indications and follow-up management of COVID-19 were identified in a PUBMED search evaluating the role of lung Ultrasound. In the current review article, 55%-60% of the patients with COVID-19 were male; the median age has been reported between 34 and 59 years. Lung Ultrasound features of COVID-19 are related to the stage of the disease, the severity of lung injury, and comorbidities. This review article provides a summary of lung Ultrasound findings in COVID-19 and clinical guidance for the use and interpretation of lung ultrasound for patients with moderate, severe and critical COVID-19-related pulmonary syndrome.

Response to Comment on Jaworska, J. et al. Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children. Diagnostics 2020, 10, 935

Thank you for the opportunity to respond to the issues raised by Nenna et al [...].

Point-of-care ultrasound by the pediatrician in the diagnosis and follow-up of community-acquired pneumonia

OBJECTIVES

To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines.

SOURCE OF DATA

A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected.

SYNTHESIS OF DATA

CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance.

CONCLUSIONS

Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

Lung ultrasound vs chest radiography in the diagnosis of children pneumonia: Systematic evidence

BACKGROUND

The aim of this meta-analysis was to evaluate the diagnostic value of lung ultrasound (LUS) in comparison to chest radiography (CXR) in children with pneumonia.

METHODS

Computer-based retrieval was performed on PubMed and EMBASE. Quality was evaluated according to the quality assessment of diagnostic accuracy studies-2, and Meta-Disc was adopted to perform meta-analysis. Heterogeneity was assessed using Q and I statistics. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence intervals (CIs) as the primary outcomes were calculated for each index test.

RESULTS

Twenty two studies with a total of 2470 patients met the inclusion criteria. Our results showed that the pooled sensitivity, specificity, and DOR for children with pneumonia diagnosed by LUS were 0.95 (95% CI: 0.94 to 0.96), 0.90 (95% CI: 0.87 to 0.92), and 137.49 (95% CI: 60.21 to 313.98), respectively. The pooled sensitivity, specificity, and DOR for pediatric pneumonia diagnosed by CXR was 0.91 (95% CI: 0.90 to 0.93), 1.00 (95% CI: 0.99 to 1.00), and 369.66 (95% CI: 137.14 to 996.47), respectively. Four clinical signs, including pulmonary consolidation, positive air bronchogram, abnormal pleural line, and pleural effusion were most frequently observed using LUS in the screening of children with pneumonia.

CONCLUSIONS

The available evidence suggests that LUS is a reliable, valuable, and alternative method to CXR for the diagnosis of pediatric pneumonia.

Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children

This evidence-based consensus aims to establish the role of point-of-care lung ultrasound in the management of pneumonia and bronchiolitis in paediatric patients. A panel of thirteen experts form five Polish tertiary pediatric centres was involved in the development of this document. The literature search was done in PubMed database. Statements were established based on a review of full-text articles published in English up to December 2019. The development of this consensus was conducted according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluations)-adopted and Delphi method. Initially, 22 proposed statements were debated over 3 rounds of on-line discussion and anonymous voting sessions. A total of 17 statements were agreed upon, including four statements referring to general issues, nine referring to pneumonia and four to bronchiolitis. For five statements experts did not achieve an agreement. The evidence supporting each statement was evaluated to assess the strength of each statement. Overall, eight statements were rated strong, five statements moderate, and four statements weak. For each statement, experts provided their comments based on the literature review and their own experience. This consensus is the first to establish the role of lung ultrasound in the diagnosis and management of pneumonia and bronchiolitis in children as an evidence-based method of imaging.

Management strategies for children with COVID-19: ESPR practical recommendations

During the outbreak of the COVID-19 pandemic, guidelines have been issued by international, national and local authorities to address management and the need for preparedness. Children with COVID-19 differ from adults in that they are less often and less severely affected. Additional precautions required in the management of children address their increased radiosensitivity, need for accompanying carers, and methods for dealing with children in a mixed adult-paediatric institution. In this guidance document, our aim is to define a pragmatic strategy for imaging children with an emphasis on proven or suspected COVID-19 cases. Children suspected of COVID-19 should not be imaged routinely. Imaging should be performed only when expected to alter patient management, depending on symptoms, preexisting conditions and clinical evolution. In order to prevent disease transmission, it is important to manage the inpatient caseload effectively by triaging children and carers outside the hospital, re-scheduling nonurgent elective procedures and managing symptomatic children and carers as COVID-19 positive until proven otherwise. Within the imaging department one should consider conducting portable examinations with COVID-19 machines or arranging dedicated COVID-19 paediatric imaging sessions and performing routine nasopharyngeal swab testing before imaging under general anaesthesia. Finally, regular personal hygiene, appropriate usage of personal protective equipment, awareness of which procedures are considered aerosol generating and information on how to best disinfect imaging machinery after examinations should be highlighted to all staff members.

Radiological diagnosis of Coronavirus Disease 2019 (COVID-19): a Practical Guide

Novel beta-coronavirus (2019-nCoV) is the cause of Coronavirus disease-19 (COVID-19), and on March 12th 2020, the World Health Organization defined COVID-19 as a controllable pandemic. Currently, the 2019 novel coronavirus (SARS-CoV-2) can be identified by virus isolation or viral nucleic acid detection; however, false negatives associated with the nucleic acid detection provide a clinical challenge. Imaging examination has become the indispensable means not only in the early detection and diagnosis but also in monitoring the clinical course, evaluating the disease severity, and may be presented as an important warning signal preceding the negative RT-PCR test results. Different radiological modalities can be used in different disease settings. Radiology Departments must be nimble in implementing operational changes to ensure continued radiology services and protect patients and staff health.

Characterisation of COVID-19 Pandemic in Paediatric Age Group: A Systematic Review and Meta-Analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a pandemic first originated in Wuhan the capital of Hubei province, China in December 2019 and then spread globally. It is caused by SARS-CoV-2. Until 1st April 2020, the number of cases worldwide was recorded to be 823,626 with 40,598 deaths. Most of the reported cases were adults with few cases described in children and neonates.

OBJECTIVES

We performed a systematic review and meta-analysis to analyse the disease characterisation in paediatric age group including the possibility of vertical transmission to the neonates.

METHODS

Articles published up to 2nd April 2020 in PubMed and google Scholar were considered for this study.

FINDINGS

The most frequently reported symptoms were cough 49% (95% CI: 42 - 55%) and fever 47% (95% CI: 41- 53%). Lymphopenia and increased Procalcitonin were recorded in (21%, 95% CI: 12 - 30%) and (28%, 95% CI: 18 - 37%) respectively. No sex difference for COVID-19 was found in paediatric age group (p = 0.7). Case fatality rate was 0%. Four out of 58 neonates (6.8%) born to COVID-19 confirmed mothers tested positive for the disease.

CONCLUSION

The disease trajectory in Paediatric patients has good prognosis compared to adults. Intensive care unit and death are rare. Vertical transmission and virus shedding in breast milk are yet to be established.

The Use of Lung Ultrasound to Monitor the Antibiotic Response of Community-Acquired Pneumonia in Children: A Preliminary Hypothesis

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality among children worldwide. Over the last 10 years, lung ultrasound (US) has been widely studied as an alternative diagnostic tool for adult and pediatric CAP with excellent results. In this case series, we describe clinical and laboratory results as well as detailed lung US findings in 6 children with CAP, showing the potential use of lung US in monitoring the response to antibiotic therapy.

Pediatric lung ultrasound - pros and potentials

Lung ultrasound (US) cannot be considered a new diagnostic imaging technique anymore, with some articles dating back 50 years. The question that hovers over it recently is why it is still not widely accepted, like chest radiography. So, have we wasted a lot of time without using lung US, or are we wasting our time using lung US? The main goals of this article are to underline all the advantages, potentials and reasons to use lung US in everyday clinical practice, but also to address the main concerns linked to this imaging tool. From the standpoint of an experienced pediatric radiologist from a tertiary health care children's hospital who has been performing this examination for more than 10 years on a daily basis, this article also addresses the most common applications of lung US, such as detection of pneumonia and neonatal lung diseases.

Lung ultrasound in pediatric radiology - cons

In the 1990s, intensivists suggested a new type of sonography: lung ultrasound, based on artefacts that receive information even from physical acoustic phenomena not directly convertible into images of the human body. They compared the artefacts from the lung zones with no acoustic window with various computed tomography (CT) patterns. They used and still use US as a tool to evaluate patients bedside, i.e. monitoring of lung recruitment. They included Lung ultrasound in what was termed POCUS (Point-of-Care Ultrasound). Lung ultrasound has been progressively extended to paediatrics in general. The most appealing novelty has been the diagnosis of pneumothorax. Lung ultrasound was developed as a support tool for critical patients. Extrapolation with mass diffusion, in the absence of appropriate training, has led to misunderstandings and dangerous therapeutic diagnostic drifts.

Lung ultrasonography versus chest radiography for the diagnosis of pediatric community acquired pneumonia in emergency department: a meta-analysis

Background

Pediatric community acquired pneumonia (pCAP) is a major public health and economic problem with a considerable impact on morbidity and mortality in children. Recently many studies and meta-analyses have shown promising results on the accuracy of lung ultrasonography (LU) in diagnosing pneumonia and potentially replacing chest radiography (CR) in pediatric population. However, previous studies establishing the accuracy of LU often used CR as reference standard and took into account different clinical settings all together. To make a more objective and specific analysis, we performed a systematic review and meta-analysis to compare the diagnostic accuracy of LU and CR for pCAP in the emergency department (ED) setting.

Methods

A literature search of PubMed and Embase databases up to December 2018 was conducted. Pooled sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio of LU and CR were calculated, and summary receiver operating characteristic (SROC) curves were drawn.

Results

A total of six studies, which included 575 pCAPs from 701 patients, were finally analyzed. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratios of LU were 96.7%, 87.3%, 8.10, 0.05, 256.68, while they were 89.7%, 93.7%, 9.97, 0.12, 175.07 for CR, respectively. The area under the SROC curves in diagnosing pCAP in the ED setting were 0.99 [95% confidence interval (CI), 0.98-1.00] and 0.97 (95% CI, 0.95-1.00) for LU and CR, respectively.

Conclusions

Our meta-analysis suggests that LU is an accurate tool in the diagnosis of pCAP in the ED setting with a superior sensitivity over CR.

Extended-FAST plus MDCT in pneumothorax diagnosis of major trauma: time to revisit ATLS imaging approach?

BACKGROUND AND OBJECTIVE

Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensitivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended focused assessment with sonography in trauma (E-FAST) during the past 6 years of experience with this technique in our Level I trauma center.

METHODS

Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 consecutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always performed and reported immediately after FAST during primary survey and before multidetector computed tomography (MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared with computed tomography (CT) findings, the reference standard for PNX detection.

RESULTS

Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room. Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was 93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4% (5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338).

CONCLUSION

Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX.

ADVANCES IN KNOWLEDGE

The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in order to incorporate it in the work-up of high-energy injured patients.

Anatomical locations of air for rapid diagnosis of pneumothorax in blunt trauma patients

Background

Bedside diagnostic ultrasound for traumatic pneumothorax is easy and reliable. However, the thoracic anatomical locations to be examined are debateable. We aimed to study the anatomical locations of blunt traumatic pneumothoraces as defined by chest CT scan to identify the areas that should be scanned while performing bedside diagnostic ultrasound.

Methods

This is a retrospective analysis of a data collected for a previous study in blunt trauma patients at our hospital during a 4-year-period with CT confirmed pneumothoraces. The anatomical distribution of the pneumothoraces and their volume were analyzed. Advanced statistical analysis was performed using repeated measures logistic regression models.

Results

Seven hundred three patients had a CT scan of the chest. Seventy-four patients (10.5%) were confirmed to have a pneumothorax. Only 64 were included in the study as they did not have a chest tube inserted before the CT scan. Twelve (18.8%) patients had bilateral pneumothorax. Seventy-six pneumothoraces were identified for which 41 patients had a right-sided pneumothorax and 35 patients had a left-sided pneumothorax. 95.1 % of the pneumothoraces detected on the right side were in the whole parasternal area with 75.6% seen in the lower parasternal region only. Similarly, 97.1 % of the pneumothoraces on the left side were seen in the whole parasternal area with 80% seen in the lower parasternal region only.

Conclusions

The current study showed that air pockets of blunt traumatic pneumothoraces are mainly located at the parasternal regions especially in pneumothorax with small volume. We recommend a quick ultrasound scanning of the parasternal regions on both sides of the chest from proximal to distal as the appropriate technique for the detection of pneumothoraces in blunt trauma setting.

Lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: A prospective study

OBJECTIVE

The purpose of this study was to describe lung ultrasound (LUS) findings at baseline and 48 hours after the beginning of treatment and evaluate how they correlate with outcome DESIGN: We prospectively analyzed patients from 1 month to 17 years of age with community acquired pneumonia (CAP) evaluated at a tertiary level pediatric hospital. At baseline and 48 hours after the beginning of treatment, history, clinical examination, laboratory testing, chest X-ray, and LUS were performed.

RESULTS

One hundred one children were enrolled in the study (13 with complicated CAP). At baseline those who developed complications presented a larger size of the subpleural pulmonary parenchymal lesions (P = .001) often associated with a complex pleural effusion (63.6%, P = .013). Those with an uncomplicated CAP presented an air, arboriform, superficial and dynamic bronchogram, as opposed to complicated CAP which had an air and liquid bronchogram, deep, fixed (P = .001). At the 48-hour control in the noncomplicated CAP group, bronchogram was more frequently superficial and dynamic (P = .050). Pleural effusion disappeared in half cases (P = .050). In all patients, neutrophilic leucocytosis with increased C-reactive protein was detected and decreased at control (P = .001). The linear regression analyses showed the switch from a deep to a superficial bronchogram as the only explanatory variable (r = 0.97, R²  = 0.94, P = .001, t = 10.73).

CONCLUSIONS

Our study describe early LUS features of CAP that might be able to predict the development of complicated CAP.

Diagnostic Accuracy of Lung Ultrasound Performed by Novice Versus Advanced Sonographers for Pneumonia in Children: A Systematic Review and Meta-analysis

BACKGROUND

Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis.

METHODS

We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers.

RESULTS

Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p < 0.01).

CONCLUSION

LUS can accurately diagnose pneumonia in children. However, this test demonstrates operator-dependent variability, with more experienced sonographers having higher diagnostic accuracy. Further work on evidence-based educational methods to train novice sonographers in LUS is required.

Diagnostic value of lung ultrasound in evaluating the severity of neonatal respiratory distress syndrome

BACKGROUND

It is still unclear whether lung ultrasound (LUS) can be used to evaluate the severity of neonatal respiratory distress syndrome (NRDS).

OBJECTIVE

To evaluate the role of LUS in assessing NRDS.

METHODS

From January 2017 to January 2018, newborns with suspected NRDS were enrolled. The LUS score and lung consolidation areas were determined. The receiver operative curve (ROC) was used to analyze the LUS score and lung consolidation to predict NRDS severity.

RESULTS

Neonates with NRDS had higher LUS scores than those with non-NRDS (23.6 ± 3.6 vs. 16.2 ± 1.8, P < 0.05). Among neonates with NRDS, the LUS scores increased with NRDS severity (18.0 ± 2.7 vs. 24.0 ± 1.7 vs. 27.0 ± 1.7, all P < 0.05). There were almost no consolidation areas in non-NRDS, while 1.9 ± 1.7 consolidation areas were observed in the NRDS group (P < 0.05). The number of consolidation areas also increased with NRDS severity (0 vs. 1.5 ± 0.8 vs. 4.1 ± 1.3, all P < 0.05). The LUS score for NRDS vs. non-NRDS showed 80.2% sensitivity and 100% specificity using a cut-off of 21.5 (Area under the ROC curve, AUC = 0.938; P < 0.001). The LUS score for severe vs. mild/moderate NRDS showed 73.1% sensitivity and 95.7% specificity using a cut-off of 25.5 (AUC = 0.944; P < 0.001). The LUS score for predicting mechanical ventilation showed 81.3% sensitivity and 88.8% specificity using a cut-off of 25.5 (AUC = 0.912; P < 0.001). The AUCs of consolidation areas were similar to those of LUS score (all P > 0.05).

CONCLUSION

The LUS score and consolidation areas can discriminate NRDS from non-NRDS and the different grades of NRDS, and predict the application of mechanical ventilation.

Chest ultrasound for the diagnosis of paediatric pulmonary diseases: a systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Chest ultrasound is an emerging imaging modality, for several paediatric pulmonary diseases.

SOURCES OF DATA

MEDLINE and EMBASE (1946-47 to 10 March 2017) were searched to collect evidence on the diagnostic accuracy of chest ultrasound, compared to other imaging modalities, for the diagnosis of paediatric pulmonary diseases.

AREAS OF AGREEMENT

Eighteen pneumonia studies, comprising 2031 children, were included for meta-analysis; the summary estimate sensitivity was 95.0% (95%CI: 90.7-97.3%) and specificity was 96.1% (95%CI: 89.1-98.7%).

AREAS OF CONTROVERSY

Other pulmonary diseases also yielded high sensitivity and specificity, but a meta-analysis could not be conducted due to a limited number of studies includable, and their heterogeneity.

GROWING POINTS

Chest ultrasound should be considered as a first-line imaging modality for children with suspected pneumonia.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research should focus on the diagnostic accuracy of chest ultrasound for the diagnosis of paediatric pulmonary diseases, other than pneumonia, comparing against a valid gold standard.

Prospective observational study of point-of-care ultrasound for diagnosing pneumonia

OBJECTIVES

The clinical diagnosis of pneumonia lacks specificity and may lead to antibiotic overuse, whereas radiological diagnoses can lack sensitivity. Point-of-care lung ultrasound is an emerging diagnostic tool. There are limited prospective data, however, on the accuracy of sonologists in the paediatric emergency department setting. We aimed to test the diagnostic accuracy of lung ultrasound for pneumonia using chest radiograph (CR) as the reference standard.

METHODS

This prospective observational cohort study in a paediatric emergency department enrolled children aged 1 month to <18 years, who had a CR ordered for possible pneumonia. Lung ultrasounds were performed by two blinded sonologists with focused training. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Radiograph and ultrasound results both required agreement between two readers, with final results determined by an arbiter in cases of disagreement. Patient management was decided by treating clinicians who were blinded to lung ultrasound results. Follow-up was performed by phone and medical record review to obtain final diagnosis and antibiotic use.

RESULTS

Of 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics.

CONCLUSION

Lung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm.

TRIAL REGISTRATION NUMBER

ACTRN12616000361404, http://www.ANZCTR.org.au/ACTRN12616000361404.aspx.

Diagnostic value of signs, symptoms and diagnostic tests for diagnosing pneumonia in ambulant children in developed countries: a systematic review

Identifying a child with pneumonia in the large group of children with acute respiratory tract infections can be challenging for primary care physicians. Knowledge on the diagnostic value of specific signs and symptoms may guide future decision rules and guidelines for clinicians. We aimed to identify and systematically review available evidence for the diagnostic value of signs, symptoms, and additional tests to diagnose pneumonia in children in an ambulatory setting in developed countries. We conducted a systematic review, searching in the electronic databases of PubMed and Embase. Quality assessment of studies was done using the QUADAS-2 criteria. After data extraction from selected studies, we calculated and summarized test characteristics (sensitivity, specificity, negative and positive predictive values) of all available signs, symptoms, additional laboratory tests, and chest ultrasonography. The original search yielded 4665 records, of which 17 articles were eligible for analysis: 12 studies on signs and symptoms, 4 on additional laboratory tests, and 6 on ultrasonography. All included studies were performed in a secondary care setting. Risk of bias was present in the majority of studies in the domain of patient selection. Prevalence of pneumonia varied from 3.4% to 71.7%. The diagnostic value of the available 27 individual signs and symptoms to identify pneumonia was low. In a low prevalence setting, (4 studies, pneumonia prevalence <10%) clinically ill appearance of the child and oxygen saturation <94% can aid a physician. In a high prevalence setting (10 studies, pneumonia >10%), additional diagnostic tests such as oxygen saturation, C-reactive protein, and white blood cell count are more promising. Chest ultrasonography showed high diagnostic value in settings with higher prevalence of pneumonia. Single signs and symptoms from medical history and physical examination or individual additional diagnostic tests are insufficient to diagnose pneumonia in ambulant children. Very few diagnostic studies are conducted in settings with low prevalence of pneumonia. Future research in low prevalence settings should focus on the diagnostic value of the combination of clinical features and additional testing possibly using meta-analysis of individual data.

Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis

OBJECTIVE

Although a clinical diagnosis, the standard initial imaging modality for patients with concern for pediatric community acquired pneumonia (pCAP) is a chest x-ray (CXR), which has a relatively high false negative rate, exposes patients to ionizing radiation, and may not be available in resource limited settings. The primary objective of this meta-analysis is to evaluate the accuracy of lung ultrasound (LUS) compared to CXR for the diagnosis of pCAP.

METHODS

Data were collected via a systematic review of PubMed, EMBASE, and Web of Science with dates up to August 2017. Keywords and search terms were generated for pneumonia, lung ultrasound, and pediatric population. Two independent investigators screened abstracts for inclusion. PRISMA was used for selecting appropriate studies. QUADAS was applied to these studies to assess quality for inclusion into the meta-analysis. We collected data from included studies and calculated sensitivity, specificity, positive predictive value, and negative predictive values of CXR and LUS for the diagnosis of pCAP.

RESULTS

Twelve studies including 1510 patients were selected for data extraction. LUS had a sensitivity of 95.5% (93.6-97.1) and specificity of 95.3% (91.1-98.3). CXR had a sensitivity of 86.8% (83.3-90.0) and specificity of 98.2% (95.7-99.6). Variations between the studies included ultrasound findings diagnostic of pneumonia, study setting (inpatient vs emergency department) and inclusion of CXR in the reference standard for pneumonia.

CONCLUSIONS

In our meta-analysis, lung ultrasound had significantly better sensitivity with similar specificity when compared to chest x-ray for the diagnosis of pediatric community acquired pneumonia.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Correlation of B-Lines on Ultrasonography With Interstitial Lung Disease on Chest Radiography and CT Imaging

BACKGROUND

We prospectively identified B-lines in patients undergoing ultrasonographic (US) examinations following liver transplantation who also had chest radiography (CXR) or chest CT imaging, or both, on the same day to determine if an association between the presence of B-lines from the thorax on US images correlates with the presence of lung abnormalities on CXR.

METHODS

Following institutional review board (IRB) approval, patients who received liver transplants and underwent routine US examinations and chest radiography or CT imaging, or both, on the same day between January 1, 2015 through July 1, 2016 were prospectively identified. Two readers who were blinded to chest films and CT images and reports independently reviewed the US interreader agreement for the presence or absence of B-lines and performed an evaluation for the presence or absence of diffuse parenchymal lung disease (DPLD) on chest films and CT images as well as from clinical evaluation. Receiver operating characteristic (ROC) curves were constructed.

RESULTS

There was good agreement between the two readers on the presence of absence of B-lines (kappa = 0.94). The area under the ROC curve for discriminating between positive DPLD and negative DPLD for both readers was 0.79 (95% CI, 0.71-0.87).

CONCLUSIONS

There is an association between the presence of extensive B-lines to the point of confluence and "dirty shadowing" on US examinations of the chest and associated findings on chest radiographs and CT scans of DPLD. Conversely, isolated B-lines do not always correlate with abnormalities on chest films and in fact sometimes appear to be a normal variant.

Lung ultrasound for the diagnosis of community-acquired pneumonia in children

Ultrasound (US) has been proposed as an alternative first-line imaging modality to diagnose community-acquired pneumonia in children. Lung US has the potential benefits over chest radiography of being radiation free, subject to fewer regulatory requirements, relatively lower cost and with immediate bedside availability of results. However, the uptake of lung US into clinical practice has been slow and it is not yet included in clinical guidelines for community-acquired pneumonia in children. The aim of this review is to give an overview of the equipment and techniques used to perform lung US in children with suspected pneumonia and the interpretation of relevant sonographic findings. We also summarise the current evidence of diagnostic accuracy and reliability of lung US compared to alternative imaging modalities in children and critically consider the strengths and limitations of lung US for use in children presenting with suspected community-acquired pneumonia.